Basic Information
| Provider Information | |||||||||
| NPI: | 1548434053 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTH MEMORIAL HEALTH CARE | ||||||||
| LastName: | |||||||||
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| MiddleName: | |||||||||
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| OtherOrganizationName: | NORTH MEMORIAL HEALTH CLINIC - BROOKLYN CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3300 OAKDALE AVE N | ||||||||
| Address2: | |||||||||
| City: | ROBBINSDALE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554222926 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635812273 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5615 XERXES AVE N | ||||||||
| Address2: | SUITE D | ||||||||
| City: | BROOKLYN CENTER | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554302819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635812273 | ||||||||
| FaxNumber: | 7635815631 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/15/2008 | ||||||||
| LastUpdateDate: | 09/03/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FROMM | ||||||||
| AuthorizedOfficialFirstName: | DAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP, CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7635814614 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | NORTH MEMORIAL HEALTH CARE | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | NM1081 | 01 | MN | PREFERREDONE | OTHER | 10B52NO | 01 | MN | BCBS OF MINNESOTA | OTHER | 111341 | 01 | MN | UCARE | OTHER |